The latest advance in computer-based telemedicine

By Dale Greer

It’s 3:14 in the morning, and Dr. Kerri Remmel’s cell phone is ringing again.

She’s at home sleeping when the device springs to life, emitting an all-too familiar cacophony of buzzes and chimes as it scoots around her nightstand.

Remmel, director of University Hospital’s Stroke Center, sits up in bed and reaches for handset while she prepares her mind to deal with whatever medical emergency is unfolding at a hospital somewhere in Kentucky.

Caller ID shows the call is coming from the emergency department of Owensboro Medical Health System hospital. An emergency room physician is on the line, seeking to consult with Remmel about a patient who just arrived by ambulance with classic stroke symptoms.

Instead of continuing the conversation over the phone, however, Remmel hangs up and sits down in front of the computer screen in her home office. Within seconds she sees live video of the OMHS Emergency Department, thanks to Internet-enabled cameras that pipe full-motion images from the hospital to her home more than 100 miles away.

The cameras actually are built into a mobile robot at OMHS, which Remmel controls remotely from Louisville using a joystick attached to her home computer. That computer, a sophisticated control station with a camera of its own, simultaneously projects live video of Remmel’s face onto a screen atop the robot back in Owensboro, providing a human face for the high-tech device.

The anthropomorphism gets even more realistic when Remmel starts to move the robot from its parking spot along a hallway at OMHS hospital. She quickly “looks” around to ensure that nothing is blocking her path, then pulls into the hall to “meet” a nurse who escorts her to the patient’s room.

The patient seems surprised as the robot glides up to the bed and Remmel introduces herself, but he quickly accepts the device as the latest advance in computer-based telemedicine.

“It’s usually less than 30 seconds before the patient ignores the technology and starts interacting with me as a normal stroke neurologist,” says Remmel, a medical doctor and Ph.D. speech pathologist who has been a professor at UofL’s School of Medicine since 2000. “Pretty quickly, they don’t think of it as a robot anymore.”

Remmel wastes no time getting to work, asking the patient a series of questions and taking a full history before conducting a complete neurological exam. She even listens to chest sounds (using a stethoscope attached to the robot), reviews diagnostic imagery and conducts a test for papillary light response by zooming in on the patient’s eyes as one of the emergency department staff shines a flashlight across them.

After consulting with the attending emergency department physician, Remmel and the OMHS team decide to give the patient an intravenous thromobolitic. This clot-busting drug, if administered in the first three hours of an ischemic stroke—resulting when an artery to the brain is blocked—can re-open blocked arteries about half of the time without the need for further endovascular or neurosurgical procedures.

In this instance, the patient’s blockage readily dissolves, and he is able to remain in his hometown hospital for full recovery, with no lasting signs of stroke damage.

In more severe cases of arterial blockage, or in cases of hemorrhagic stroke in which extensive bleeding occurs, the team likely would have decided to stabilize the patient and transport him by to Louisville, where University Hospital offers the broadest range of state-of-the-art stroke therapies in Kentucky,

In the past, the correct course of treatment might have been a very tough call. Low demand means that many hospitals don’t keep full-coverage sub-specialists like neurologists or stroke physicians on staff, Remmel says. Even a regional hospital like OMHS has just one neurologist on duty, and he can’t cover all medical emergencies 24 hours a day, seven days a week. Some counties have no neurologists at all.

As a result, many emergency physicians, internists and general practitioners are faced with the prospect of prescribing clot-busting drugs without the benefit of neurologic consultation. Unfortunately, such treatments can cause their own problems if administered improperly or given to a patient who should be treated differently.

“This is not a non-benign procedure,” notes Dr. Robert Knight, chief of the Department of Emergency Medicine at OMHS.

Of course, physicians have the option of consulting with a neurologist over the telephone, but phone consults aren’t wholly reliable.

“It’s very difficult to determine over the phone if a patient is, indeed, having a stroke,” Remmel says. “There is simply no way to examine them. So more often than not we would elect to have the patient transferred to Louisville out of caution.

“In stroke, time saved is brain saved, and we wouldn’t want to take a chance on failing to provide appropriate, timely care because of a misdiagnosis during a telephone consultation.”

These issues have now largely evaporated, thanks to the robot, an RP-7 “remote presence” machine manufactured by InTouch Health of Santa Barbara, Calif.

“What I’m able to do with the robot is go to the bedside of the patient, take a history, do a full neurological exam and decide on an appropriate course of treatment just as though I were there in person,” Remmel says. “That helps ensure that the patient gets the right diagnosis and the right treatment at the right time and the right place.

“The nice thing is that we’ve been able to keep more patients at their home hospitals by using the robot. This saves bed space for us in the Stroke Center at University Hospital, and the patients are relieved to find out either that they weren’t having a stroke or that they could stay in their own communities for appropriate care.”

Knight, who oversees the state’s busiest emergency department, appreciates the assistance.

“We treated 67,000 patients last year in our ED, so we see a lot of neurologic cases,” he says. “We’re the first ones to make the call about how to provide care, and we hate to make those calls on our own. We like to have a neurologist who can consult with us, so the robot definitely gives us a nice safety net. We’re happy to have it.

“The technology is so new and different we’re still trying to find the best way to integrate it clinically,” Knight adds. “On your traditional algorithm of patient care, ‘Get the robot out’ isn’t something that normally comes to mind. So we have to make a conscious effort to think about using it sometimes. But it’s been a great advance in patient care. It gives us access to specialists we wouldn’t otherwise have.”

Only the Beginning

OMHS was the first hospital to partner with UofL when the robots were originally fielded last November, but several other institutions followed suit within a matter of weeks—including facilities in Campbellsville, Hopkinsville, Lebanon and Pikeville—to establish the state’s first robot network.

Eleven partner hospitals now use the robots, which have been used for scores of consultations with UofL physicians since their introduction. The university ultimately hopes to expand the number of partner hospitals to 30, mostly in Central and Western Kentucky.

The number of control stations also may increase as disciplines outside neurology begin using the robots. UofL currently has five control stations at various locations, including University and Kosair Children’s Hospitals, as well as two laptop stations that offer portable connectivity anywhere a wireless signal is available. Remmel has one of the laptops, while the other is assigned to UofL’s Dr. Alex Abou-Chebl, one of the fewer than 15 interventional neurologists in the country.

Abou-Chebl is a key resource for smaller hospitals, Remmel says, because he can access the most advanced technology to identify patients whose strokes can be reversed, even if they present outside the three-hour window in which clot-busting drugs are traditionally effective.

If the patient qualifies, Abou-Chebl can use a number of different devices to go into the brain’s vessels and remove, break up or pull out clots, saving patients from a lifetime of debilitating effects.

In March 2008, he became the first physician in Kentucky (and only one of a handful of physicians nationwide) to use a recently FDA-approved device that sucks clots out through a tiny catheter using a microwire that acts as a plunger to break up obstructions.

While most of the robots’ use to date has been in neurological consultation, Remmel says they have nearly limitless potential.

“This goes way beyond stroke, and that’s what I’m really excited about,” she says. “We’re talking about expertise that the university could provide to the state in multiple disciplines across all of UofL Health Care, including specialties like endocrinology or hepatology.”

Neonatology has, for example, already begun using the robots at three hospitals—Campbellsville, Owensboro and Glasgow—instead of telephone consultations for the care of sick infants, says Dr. Tonya Robinson, an associate professor of pediatrics and a neonatal medicine specialist at UofL.

“The robot provides an immense improvement over telephone consultations,” Robinson says.

“Being able to see and maneuver around the patient is just a phenomenal advantage. About 90 percent of our business involves babies with labored breathing, and that can be described over the phone in many different ways. But when we can actually see the baby, observe how the chest is moving and hear the grunting sounds, it helps us better assess whether we need to arrange transport immediately.

“At one extreme, you might have a baby with issues, but is that a baby who could be watched a little bit longer at his home hospital and avoid being transported to Louisville? If so, the baby would get to stay with the family and improve closer to home.

“Otherwise, the baby is going to be separated from his mother for at least two days, in some cases unnecessarily, and the family will need to drive back and forth to Louisville.

“At the other extreme, we might have a critically sick infant who is born at a facility where the staff isn’t trained to stabilize the baby, and they want our help providing care while the transport team is enroute.”

Dr. Larry Cook, UofL’s executive vice president for health affairs, says this kind of scenario is a “win-win situation for everybody,” especially since the robots are being provided at no cost to the partner hospitals.

“You take a community that doesn’t have a neurologist or a neonatologist, and you’re able to put someone like Dr. Remmel or Dr. Robinson right there at the bedside instantaneously. That’s an amazing thing,” he says.

At the same time, patients get to stay at their home hospital if possible, or they are referred to another hospital when appropriate for the best state-of-the-art care.

“Part of our responsibility at UofL, as an academic medical center, is to provide leading-edge medical care across innumerable disciplines to as many parts of the state as possible,” adds Cook, who was an early champion of the program and provided $1 million in seed money to cover start-up costs. The effort is sponsored by University Hospital.

“These robots provide a very efficient way to extend our expertise into partner hospitals, helping them augment existing patient care virtually overnight.

“It really is the next best thing to being there.”